ADHD Notesheet

ADHD - Diagnosed in school aged children (up to 12); Difficult to focus on tasks or follow instructions -\> problems @ school & home - Normal kid development - Mastered cognitive operations to comply with rules; Stop acting impulsively - Pays attention to parents and...

ADHD - Diagnosed in school aged children (up to 12); Difficult to focus on tasks or follow instructions -\> problems @ school & home - Normal kid development - Mastered cognitive operations to comply with rules; Stop acting impulsively - Pays attention to parents and teachers even if distraction; sits still despite boredom - Develops self control important since need to comply w/ directions, stay on task @ school, play appropriately - Self regulation- ones own control of emotion cognition and behavior ( involves automatic and controlled processes - Dual influence framework self control -- impulsigenic processes (reward sensitivity, sensation seek, reactive undercontrol, cravings, anxiety)volitional processes (executive function, metacognitive strategies) - Effortful control-regulation of thought action emotion behavior; biopsychosocial model important; up young children declines impulsivity & distractibility (MARSHMALLOW TEST) (STROOP = exec funt) - Executive function- cognitive processes underlying goal directed behavior (inhibition, working memory, shiftin) - ADHD kid development - Trouble w/ self control; struggle to comply with instructions; labeled problem children - noncompliance can be explained by many factors including neurological dysfunction - Prevalence: 3-7% children US; 65% (book) 50-70% (lecture) children will have symptoms as adults; 4.4% adults - Adult: decline symptom overall; symptom may change; subthreshold symptom remain; high persistence impair - Sex difference: child (male:female) 3:1 (diagnose not have); adolescence 2:1; adult 1:1 - Core symptoms/Diagnosis: 2 clusters -\> hyperactivity/impulsive and inattentive (6+ symptoms) - Hyperactivity -\> in motion when need to sit still; Impulsive -\> can't delay response and acts w/o look repercussions - Symptoms of both are closely related; boys more likely than girls - Fidgets w/ appendages; squirms in seat; leaves seat when expected not to; runs/climbs when not appropriate; cant play quietly; often on the go; "driven by motor;" talk excessively; blurt out answer before talk finish; trouble wait for turn; interrupt or intrude others - Inattentive -\> hard time organization & task follow through; distracted by external stimuli - Attention 2 detail; careless mistake; maintain attention; not listen when direct spoken to; not follow instruction; fail to finish; trouble organizing tasks; avoid dislike tasks w/ sustained mental effort; lose things needed for tasks; easily distracted by extraneous stimuli; forgetful in daily activities; daydreaming - Sluggish cognitive tempo (inconsistent alertness) frequently observed - Can be diagnosed: combined type 55%, predominately inattentive 27% (late diagnose), predominately hyperactive/impulsive 18% (most male; rare after kindergarten) - To be diagnosed symptoms must significantly impair functioning in major life domains & be inappropriate for dev lvl - Impairment domains: low academic achiev; repeat grade/suspended/not graduate hs; unpopular/disliked/rejection; comorbid disorders like learning, depression, anxiety, ODD; risk for drug alc abuse - Etiology/Cause - Not a single cause; risk factors range genetic-\>familial-\>cultural; genetics/neurophysio cause majority (twin studies) ADHD due 75% genetic variation (book) 80% heritability (lecture); polygenetic model; epigenetics; chromosomal abnormality; rare & common variants - Protective factors: resilience-\>adaptation (resiiance) despite adversity (reflects combo contributions of pro factors); pro factor-\> individual, social, family characteristics assoc w/ positive adaptation - Genes linked are linked to neurotransmitters serotonin & dopamine; reduced brain volume in prefrontal cortex, corpus callosum, anterior cingulate cortex, basal ganglia, cerebellum (assoc w/ organization, impulse control, motor activity); frontal, ACC, corpus, temporal, striatal 1) under responsivity to stimuli 2) lower \# dopamine receptors; environment may cause minority of ADHD cases - Neurotransmitters: dopamine, norepinephrine, epinephrine, biosynthetic pathway of catecholamines - dopamine=appetitive reward (want & novelty), movement, motivation, habit form (also attention, sleep, lactation/birth, memory, arousal, etc) 2 type: tonic (w/o stimulus; steady level); phasic (w/ stimulus (reward coming); on top of tonic; short burst) - tonic phase low phasic has to make up for it; appetitive dop phase fucked - norepinephrine=vigilance, attention vigil, arousal, alertness, fight or flight (also mood, memory, sleep wake cycle) - Envr risk factors increase ADHD risk by disrupting early dev & compromising integrity of CNS; factors include-\> low birth weight, malnutrition, alc & nic use during pregnancy, envr toxins like lead pesticides in early life; family & social characteristics assoc w/ up vulnerability (nonspecific risk-vuln to any or 2+ disorder; specific risk-vuln to 1 disorder) - Differential susceptibility model = orchid dandelion - Poor parenting may up symptoms but no cause ; sugar no, food additives no but cause some hyper in subgroups; allergies no; thyroid no; screen time/tech no; hypo(er)glycemia no - Comorbidity -\> common (ODD 40%, CD 14% (likely hyper/imp or combo); other (tics 11%, mood 4%, anx 34%) - Treatment - Less severe problems=contingency management (parent trained; reward punishment; more needed usually - Stimulant meds treat core symptoms (impulse control, time-on-task, compliance, hyperactivity, disruptions) - Neg side effects: growth & appetite suppression; up blood pressure; insomnia; mood changes (can be avoided w/ careful monitoring and dosage adjustment); long term != heart problems or drug abuse - Parent management training -\> immediate, consistent, powerful reward & punishment; summer camp same premise - school intervention-\> token reinforcement (earn points by not break rule; secondary reinforcer as can be redeemed; most effect: token provide good behavior & token remove bad behavior); time out (only when fail respond token removal or severe disruption; no access reinforcement & yes monitor behavior during); daily report card (keep track if meet goals \@school; info sent home each day; parent integrate info into home program); educational services & accommodations (direct intervention in reading, math, etc; 1:1 educator; envr accommodations: extra test time or low-distraction setting) - Meds most effective in beginning combo was same in beg; comb less disruptive than meds; beh==lower dose med Conduct - Oppositional Defiant Disorder (ODD) - characterized by: sustained pattern of negativistic behavior, hostile and defiant behavior; diagnosed before 8; boys\>girls; underlying dimensions-\>aggression, noncompliance, temper loss, low concern 4 others; - Diagnosis DSM (4+ symptoms)-\> anger irritable mood (lose temper, touchy or annoyed, angry & resentful); argumentative defiant behavior (argues w/ authority, defies/refuses comly w/ request from authority or rules, annoys others, blames others for mistakes or behavior); vindictiveness (spiteful vindictive 2ce in past 6 months) - Conduct Disorder (CD) - Characterized by: persistent pattern of violating social norms & rules; may have callous unemotional traits (CU)(lack empathy & remorse, shallow emotion); 2 subtypes: child onset & adolescent onset (teen limited: rebellious, reject status hierarchy, assoc w/ bad peers; causal mech: exaggeration of normal dev process of identity); aggression: behaviors meant 4 immediate harm (instrumental/proactive=planned (more likely callous); reactive in response to provoking; overt=physical behaviors or name calling; covert=indirect like rejection exclusion) - Relational aggression: males-\> instrumentality, physical dominance, competition; female-\> cooperation, interpersonal sensitivity, valuing relationship; damaging or threatening to damage ones relationship or acceptance; physical 16%m 1%f; relational 17%f 2%m - Diagnosis DSM (3/15 needed) - Aggression to people & animals-\>bullies threaten intimidate, physical fight start, weapon, physically cruel 2 people, physically cruel 2 animal, stolen while confronting, forced sex - Destruction to property-\> fire setting, destroyed others property (not fire) - Deceitfulness and theft-\> broken in car/house, lied 4 goods or favors or avoid obligation, stolen items of nontrivial value w/o confront - Serious violations of rules-\> stay out @ night despite parental disapproval (start b4 14), run away from home overnight twice while living w/ parents or once w/o returning for long period, truant start before 13 - Prevalence: childhood ODD\>CD teen ODD==CD - ODD lifetime prevalence =10% (12% male 9% female) - CD lifetime prevalence = 9% (12% male 7% female) - Comorbidity-\> ADHD 65-90%, anxiety 22-33% community 60-75% clinic, depression unclear - Developmental pathways - Multifinality-\> same thing lead to many different diagnosis; Equifinality-\> lots different things lead to same diagnosis - Pathway model-\>Mechanisms that are hypothesized to underlie continuity (stability) and discontinuity (change) are key to the study of developmental psychopathology - Developmental perspective-\> dimension (noncompliance), dev task (internalize rules), normative misbehavior (goal directed noncompliance), clinical indicator (stubborn pervasive noncompliance - More severe ODD the more stable disorder is; ODD increases risk of CD but not more severe forms of ODD; CD stable over time \>50%, family instability & peer factors contribute to worsening - Etiology-\> coercion model: inconsistent discipline; irritable explosive discipline, inflexible rigid discipline, low supervision and involvement (child initial misbehavior and disobedience escalates due to parent child interaction (uses classical operant conditioning and social learning and reinforcement is key) - Step 1: intrusion of family member on kid activity; step 2: child counterattack; step 3:adult stop scolding and command compliance; step 4: child stop counter attack; this reinforces parent giving in (stops the aversive child behavior) Etiology - Key message: Externalizing behaviors have a multifactorial etiology, both involving common genetic variants and a multitude of environmental factors; 1) possible biological mechanisms underlying externalizing behaviors 2)heritability & genetics of ext beh 3)multifactorial aspect of ext beh - Ext beh on bell curve left end maladaptive middle normal right end pathological - Bio systems -\> dopamine (VTA produce), serotonin (DRN produce), HPA axis (stress response); dop and sero bind to receptors to exert functions; MAOA catalyzes oxidative deamination of dop and sero; low MAOA activity==brunner, aggression, ADHD, ASD; HPA axis (glucocorticoids bind to receptors to exert function) - Heritability of externalizing behavior 40-50% ADHD 80% with 14% explained by genetic varaints Externalizing behaviours have a polygenic etiology, meaning that many genetic variants with small effect sizes contribute to the phenotype These genetic variants are (among others) located in genes involved in dopamine, serotonin, and stress signaling Externalizing behaviours are not only genetic, but there are also environmental risk factors Externalizing behaviours have a multifactorial etiology, involving both common genetic variants and a multitude of environmental factors The combination of these genetic variants and environmental factors is different for every individual Psychopathy - HARE psychopathy checklist - Factor 1 interpersonal affective (interpersonal facet-\> superficial charm, grandiose sense of self worth, pathological lying, conning; Affective facet-\> lack of remorse/guilt, shallow affect, callous lack of empathy, failure to accept responsibility for actions) Factor 2 chronic antisocial lifestyle (lifestyle facet-\> need for stimulation prone to boredom, parasitic lifestyle, lack of realistic long term goals, impulsivity, irresponsibility; antisocial facet-\> poor behavior control, early behavior problem, juvenile delinquency, revocation of conditional release, criminal versatility) - Brain differences - reduced responses in set of cortical (ventromedial prefrontal) and subcortical (amygdala) regions to emotional stimuli; reduced neural responsiveness to reward within striatum & VPC; less response to punishment; lower volume & cortical thickness across four lobes - Prevalence - Psychopathy 1%, ASPD 4%, 80-90% of people with psychopathy meet ASPD, 25-40% of people ASPD meet psychopathy, almost all psychopath have ASPD; not all ASPD are psychopath - Personality disorder-\> relatively persistent (not always constant) psychological features of a person; difficulties understanding self and others - Psychopathy-\> a cause state or manifestation of psychological dysfunction - ASPD-\> pervasive pattern of disregard for and violation of the rights of others (3+ criteria age 18+ & CD before 15) - Failure to conform to social norms with respect to lawful behaviors, deceitfulness (lie aliases conning), impulsivity or failure to plan ahead, irritability and aggressiveness, reckless disregard for safety of self and others, consistent irresponsibility, lack of remorse - Cluster B - ASPD-\> pattern of disregard for and violation of the rights of others, BPD, NPD-\> pattern of grandiosity need for admiration and lack of empathy - PCL R (psychopathy checklist revised 20 items cutoff score 30 of 40; high score= impulsive, aggressive, low empathy, Machiavellianism, lack of social connectedness, violent offending - PPI or PPI-R psychopathic personality inventory 154 items into 8 facet scales around 2 factors: fearless dominance FD (social potency, stress immunity, fearlessness) and self centered impulsivity SCI (egocentricity, exploitativeness, hostile rebelliousness, lack of planning) Interventions - Assessment and Diagnosis - Definitions: Assessment -- systematic collection of relevant info used to evaluate clinically significant psychopathology; Diagnosis -- is the method of assigning individual children to specific classification categories; Classification -- is a system for describing important categories groups or dimension of disorders - Categorical Classification-\> clinical CC assumes there are groups with relatively similar patterns of disorder; best known classification DSM from APsychiatricA (DSM5TR current); classifications-\> categorical models of psychopathology & dimensional models of psychopathology; advantages of diagnosis-\> (standard rules, everyone same system, communication, easy assessment, prevalence rates, guide treatment decisions); disadvantages-\> (restrictive, several abnormal behaviors must be present and cause significant problems, definitions change w/ time & research, misguides assessment & treatment) - problems for classification-\> (heterogeneity (The ways in which children with the same disorder or diagnosis display idiosyncratic sets of difficulties or symptoms), comorbidity (cooccurrence 2+ disorders), differential diagnosis, diagnostic efficiency); diagnostic decision making-\> false neg clinician says no but child does have, false positive clinician says yes but child not have, true positive and false negative is sensitivity, true negative and false positive is specificity; - Types of assessment-\> survey, physiological, interview, standardized test, projective measures, observation - Stages of assessment-\> gathering background info (referral question presenting prob broad questionnaires CBCL PCL5), Intake interview (family social developmental school history, present functioning relationships symptoms, expectations hopes fears strengths competencies), face to face testing (IQ achievement maybe neuropsych, narrow questionnaires), Observations (structured tasks, school), Put it all together (diagnosis, recommendations, treatment plan), feedback session (provide diagnosis, psychoeducation, discuss treatment plan) - Parent teacher and youth questionnaires-\> get symptom counts/severity, risk & protective factors, internalizing externalizing - Interviews-\> structured, semi structured, unstructured, w/ parent and child; clinical interview-\> focus on DSM criteria, always include parent, structured or unstructured, assesses symptoms duration and impairment - Treatment for ADHD: medication and behavior therapy - Evidence based treatments: CNS stimulants (raises tonic dopamine), behavioral interventions, school based interventions, combination treatments - Non evidence based treatment: individual therapy, play therapy, cognitive therapy, support groups - Medication: most common stimulants-\>methylphenidate (Ritalin, metadate, concerta, daytrana, focalin) amphetamines (Adderall Vyvanse); nonstimulant meds-\> NSRI (SNRI) (straterra atomoxetine); guanfacine or clonidine (used to treat high blood pressure intuiv) - Address low arousal component (all stimulants target dopamine) - Methylphenidate-\> (DAT dopamine transporter inhibitor, neuron cannot pick up dopamine in synapse-increase tonic dopamine); amphetamine-\> (stimulates neurons to release more dopamine to the synaptic cleft without a direct reward stimulus-increase tonic dopamine) (heterodimer all psychedelics work on same one) - Behavior therapy-\> behavioral parent training, school based interventions (daily report card, clear structure, homework organization planning), summer treatment program - Multimodal treatment study of children with ADHD (MTA) see ADHD section - Pros med: reduce symptoms, reduced parent stress, quick gain, cheap Cons med: no long term benefits, side effects, stunts growth - Pro therapy: reduces functional impairment, reduces parent stress, no side effect, more palatable Con therapy: lots of work 4 parent, no long term benefit, more expensive time consuming - Start with behavioral then add meds - Treatment for conduct problems: keep sociocultural model and ecological models in mind (Bronfenbrenner macrosystem thing) - Behavioral parent training==most effective; encourage positive behavior consequence and structure for negative behavior - Common components: attending strategies, rewards, planned ignoring, effective commands, transitional strategies, point system, time out - Child game activity" parent role-\> attend, label praise, ignore minor misbehavior; child role-\> play be kid, be a bit defiant, make bit of mess - Attending-\> set aside time to join child in activity of its choice; sincere interest; enthusiastic descriptive, positive commentary and praise - Labeled praise-\> describes a specific behavior to teach child what behaviors are valued; sincere enthusiastic tone and nonverbal rewards - Active ignoring-\> behaviors child uses to get attention; ignore target misbehaviors (aka no talking gesturing facial expressions physical or eye contact); praise when good behavior starts - Parent game activity: parent role-\> clear instructions, attending and labelled praise, maybe time out child role-\> make fuss, don't respond to unclear instructions, respond to clear ones - Effective instructions-\> get attention eye contact, provide transitional warning, firm calm tone, commands one at time, no vague request, no questions let's, tell child what to do, no lengthy explain, praise compliance, consequence noncompliance - Creating & follow through consequences-\> time out (not fun location, 5 min active ignore, at end give instruction again, praise or repeat), loss of privileges, work chores - Daily report card